From the blog of Claire Wright. P!EASE READ EVERY SINGLE WORD OF THIS LONG BUT VERY IMPORTANT POST:

“A recommendation urging no further community hospital bed closures in Devon has been voted down by Conservative councillors on Devon County Council’s Health and Adult Care Scrutiny Committee.

The recommendation, which was debated on Thursday (22 November) was part of a set of measures set out in a scrutiny spotlight review aimed at supporting the care at home service (or rapid response) to be more effective.

Highlighted in particular as a challenging area were services for end of life care, which have been put under considerable pressure, especially since the loss of community hospital beds.

I chaired the spotlight review, which took place this summer and published its findings last week in a report that can be found here

Also struck out by conservative councillors was a proposal to review all intermediate care provision (bed based care for people are not yet well enough to return home after hospital) with a view to reopening some community hospital beds on a flexible basis.

Over 200 Devon community beds have been cut in the past five years and the facility known as rapid response, which provides care at home, was supposed to have been beefed up to cope with the extra demand.

Unfortunately, this does not appear to have worked due to a lack of staff, particularly in the Exeter and East Devon area.

The local NHS and Devon County Council have (and are still) advertising extensively but still many vacancies remain.

Some GPs, particularly those in East Devon, have outlined problems with availability of paid carers (see appendix to the main report), and stated that they have lost confidence in the system and are instead admitting patients to hospital, because it takes so long to arrange care, or because care is simply unavailable.

Rapid response was established to avoid hospital admissions where possible and instead care for people in their own homes.

Care of dying patients, very sadly, appears to be the worst hit, with a director from Hospiscare confirming that care from rapid response is too often not available.

Ann Rhys, assistant director of care with Hospiscare, told councillors that in a three month period over the summer, 40 end of life patients were unable to access rapid response.

In one month during the summer one East Devon Hospiscare nurse alone reported eight instances where no care was available.

Hospiscare has seen a “large increase” of patients dying in their in-patient unit in the past 12 months, as a result.

The community hospital beds recommendation proposed to be deleted by Exmouth councillor, Richard Scott was seconded by Cllr Paul Crabbe, who described the proposal for no further bed cuts as “nonsense.”

Cllr Scott claimed there was no evidence for the proposal and replaced it with what I can only describe as a rather meaningless collection of words, which I had to ask for clarification on twice.

Voting in favour of deleting the community hospital bed recommendation was one Labour councillor and all the Conservative councillors on the committee, except chair, Cllr Sara Randall Johnson who abstained. A LibDem councillor and I voted against.

The rest of the recommendations, which can be found in full here at the beginning of the report were supported with one or two with minor tweaks – including writing to the chief executive of the NHS and the Health Secretary about a review of wages for paid carers. https://democracy.devon.gov.uk/mgConvert2PDF.aspx?ID=22439

Also, remaining was a recommendation urging the local NHS to review its funding for Hospiscare and other local hospices.

Hospiscare receives £1m from the NHS and must fundraise for the remaining £7m and this is becoming harder as pressures on the service increase.

Before the vote I reminded the committee of the words of the county solicitor who addressed the committee earlier this year on our role on the committee as community representatives.

I said we were on the committee as representatives of local people not mouthpieces of council officers and NHS managers.

The spotlight review report is a summary of discussions and it is not the convention to publish witness statements. However, Local Medical Committee Secretary, Dr Paul Hynam, Sidmouth GP, Dr Mike Slot, Hospiscare director of care, Ann Rhys and Exeter based Patient and Public Involvement lead, Richard Westlake have kindly given consent for me to publish their full witness statements, which are below:
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Witness Session: Dr Slot, GP at the Sid Valley Practice
Dr Slot followed his original representation to committee and outlined his concerns, namely that the rapid response service was a well thought out service, with helpful and creative staff.

However there have been a number of occasions when the service was unavailable. This had meant that patients had had to be admitted to hospital. Dr Slot had experienced two occasions last year when there had been no capacity and patients had to be admitted but, on the most recent three occasions that he had contacted the single point of access, they had been able to help and admission had been avoided.

Dr Slot is a member of Devon Local Medical Committee and had gathered some feedback from other GP members and from his own practice. The feedback referred mostly to capacity issues.

Views of other GPs
Dr Slot had contacted GPs across Devon to understand their experiences. Overall there was a mixed response with colleagues.
– Dr xxx said RR had been working well
– Dr xxx now had to ‘force himself’ to ring the contact number. Following a number of occasions when the service had been unavailable.
– Dr xxx had also had issues in North where the service was unavailable.
– A Hospiscare nurse in East Devon had experienced eight instances in the last month where there was no care available.
– One of the GPs in East Devon had had three recent experiences when there had been no capacity and patients needed admission.

Dr Slot has undertaken to get the agreement of colleagues to share more fully their responses with the Spotlight Review.
Capacity.

Dr Slot was clear in highlighting that in his opinion the issue was one of capacity, not skills or training with staff. The single point of access will often say ‘there is not capacity today and to call tomorrow’. The impact on the patient may be that they are unsafe to stay at home and have to be admitted to hospital.

This includes patients who are at the end of their lives, who may have to die in hospital when they would have preferred to have died at home.

The impact on the GP for the service being unavailable is usually one of time, where alternative lengthy arrangements need to be made or repeated phone calls to the single point of access to try to put something in place. Whilst GPs may only ring the service an average of twice a month, there is significant reputational damage if the service is repeatedly unavailable.

Looking at the figures for referrals and in particular when the service was unavailable, GPs had expressed concerns about whether all of the calls were being logged. Within the figures the number of calls logged does not differentiate between different patients, and a patient could be referred more than once if there was no capacity. There is concern that these calls are not being logged anywhere in the system. The outcome of declines is not recorded and could be an admission, or a decision to stay at home.

Within the NHS there is the generally accepted capacity of hospitals ideally having bed occupancy of 85%, allowing for flex in the system. In community services the research has not been carried out to understand what the ideal service take up is, however suspect that it is similar. It feels like the service is often working at 100% capacity.

Timing of Referrals
Referrals frequently come in later in the day (when relatives worry towards end of day and call GPs) but most staff are then going home. Early referral would be more helpful, but is not always possible.

Ann Rhys
Assistant Director of Care, Hospiscare

Hospiscare covers the area of Exeter, East and Mid Devon, including Tiverton, Crediton, Okehampton, North Dartmoor, Dawlish, Exeter and the Coast to Seaton, Axminster and Honiton. Working alongside NHS colleagues, together with inpatient and community teams, they work in support to co-ordinate packages of care to prevent unnecessary admissions. RR support impacts on many patients and families across the whole area.

Issues with RR
Exeter works well and is responsive, but the majority of RRS teams struggle to cope. Hospiscare log as many instances as they can where patients need access via RR and, in the last 3-4 months, around 40 people have been unable to access RR.

There have been instances in the RR team covering East and Mid Devon (Seaton/ Ottery/ Crediton), when there is no capacity, for the RR team to say to “put on the reject list”. For RR teams to use this phrase is very poor practice. Also, when there is no capacity, the patient’s name is not taken and, in all likelihood, is probably not logged.

When there is no capacity, this is very time consuming as a further call to RR needs to be made, thereby creating a huge impact on community teams. Clinical nurse specialists could make phone contact 3-4 times per day

Other instances have occurred where families are waiting for RR to arrive, only to be phoned and told that RR has been delayed and, as a result, sometimes it may be that pressure is exerted to not come at all – and care is then removed – with the potential risk of being admitted to the RD&E

A further situation arose when the RRS was phoned about a Mid Devon patient who was registered with a GP in Crediton, but lived closer to Tiverton, the RRS said that although there was a carer available in Tiverton, they could not access that carer because of the patient being registered in Crediton and not Tiverton.

End of Life patients
A large proportion of patients prefer to remain at home for end of life. If patients cannot be supported, the Hospiscare community team help to try and provide what is needed. I have received almost tearful feedback from Hospiscare nurses frustrated that it is difficult to source the care required, with many patients close to end of life who just wish to stay at home and this is creating a huge strain on the nurses involved.

Hospiscare have seen a large increase of patients dying in their 12-bed Inpatient unit over the last 12 months. Help is required when patients leave their Inpatient unit to go home, and there is a gap in support here.

We see a lot of people retiring into this area this can mean that there is a lack of social support with families being at times geographical spread, or when this is not the situation families taking on the carer role which can result in a post bereavement risk. Trajectories of illness currently seem to be that patients are stable for longer but then are deteriorating very rapidly at the end of life, which can result in crisis needing urgent support which is not available.

Community hospital closures
Up until 2012/13 the RRS worked well, but this changed when the community hospitals closed and has created a huge impact. Patients say they prefer to be at home or in a community hospital but, with the closure of community hospitals, there are not enough care packages to support this. Acute setting deaths are increasing in some areas, while home deaths have decreased. Consequently, the closure of community hospitals could be said to have had a poor outcome for a number of our patients.

Also, since the closure of further community hospitals last autumn, there has been an increase in Hospiscare patients referred to our inpatient unit due to social care breakdown.

Hospiscare@Home teams
The Hospiscare@Home team that operates in Exmouth, Budleigh Salterton and Seaton evolved on the back of decreases in support options for patients at the end of life after community hospitals began to close.

Our statistics show the Hospiscare@Home teams are able to keep over 90% of their patients at home if that is their preferred place of death and nearly 90% of these patients would otherwise have been admitted to an acute setting. Hospiscare do everything they can to provide help at home if there is a Hospiscare@Home team available.

NHS community nurses work alongside Hospiscare@Home teams and,where these teams do not exist, the NHS community nurses and our own Hospiscare Clinical nurse specialists go above and beyond to try and support people to remain at home.

Hospiscare Funding
Around £1m of funding is provided by the NHS each year to support the running of Hospiscare, but an additional £7m is needed to be raised from funding events, charities etc. Hospiscare can choose where to invest these monies, but strains are becoming more intense.

Conclusion
Devon has an ageing population with complex needs that need responding to, and this situation will continue to grow. Some people have retired to this area, without family nearby, and are often on their own and require support. Any season of the year can be difficult, but winter tends to be a busy period, and this is when we saw an increased dependency on our inpatient beds this year.

The sadness is that RRS used to be a good service, but cracks are now appearing through the lack of support available. The problem with RR is one of capacity – a lack of staff.

Dr Paul Hynam
GP and Medical Secretary, Devon LMC

GP Feedback
Although Dr Slot had made further enquiries requesting feedback from other areas, nothing further had been received apart from that already provided from the East, which mostly highlighted difficulties in capacity, however, he felt the RRS were working flat out and were fully engaged in trying to keep patients out of hospital.

Why isn’t it RR working?
There is no clinical experience in either Out of Hospital teams or Admissions to support some patients. Although there are community matrons, they are not sufficiently qualified and the teams lack clinical experience. Also, the service is structured in such a way that it is weighted towards non-qualified people, but it is qualified nurses that are needed, across all areas of Devon.

South Devon and Torbay CCG have intermediate care in place where there are qualified GPs on the team looking after patients. This model is proving much more successful and a move towards this model of care in other areas would be welcome.

Most of the hospital Community Urgent Care teams (which are similar to RRS) are too busy engaged in facilitating the discharge of patients, rather than going into homes to support, but no attempt is made to plug this gap. The impact of this means there is less care being provided at home and more patients having to be admitted.

From the point of discharge, some patients who might have gone into a community hospital are now going home, but the lack of available staff to support those patients, mean that re-admission numbers are high.

GPs try to avoid admission because the patient is much better looked after at home thereby avoiding the risk of infection.

When patients are discharged, it feels like there is no support, as the right support team is not in place. Patients are not discharged too early, but it is the team that cannot support them, e.g. out of hours care for washing, dressing and night sitting.

It is hard to find care for this. I can ring RRS on a Thursday or Friday and be told there is no care available until the following week. I then have to re-admit – this change has happened in the last couple of years.

Over the last few years, it has become much more likely that the RRS is unable to help. GPs are often being contacted to manage problems for patients who should really be in hospital. There is an early response team that should be helping them here, but this does not happen, and is a concern for many GPs.

I am starting to give up on using RRS as it is so time consuming. For instance, I can spend a long time on the phone to RRS and then wait for a call back, sometimes hours later, only to be told there is no care available. Using the hospital admission process is much quicker.

GP practices however are working much more closely, with many GP surgeries merging and some sharing the same ICT infrastructure.

Recruitment/Retention
The lack of capacity within the RRS means the teams do not have enough time. Additional workforce is needed across all sectors and there is currently a big international recruitment drive taking place in Devon. Medical students don’t want to come into the profession, as they see it as a ‘bad deal’, i.e. low pay and stressful conditions. Staff who are unsupported become stressed and leave.

When training was slashed in 2010, it was reported that there would be a knock-on effect in 7 or 8 years’ time – and this is now happening.

Yellow Card scheme
Dr Hynam said he used the yellow card system and that ensuring the patient can safely discharge to their home is the absolute minimum.

Mr Richard Westlake
Chair of Exeter Patient and Public Involvement Group
Meetings of the Exeter PPG are held every quarter where two representatives from each surgery in Exeter attend to discuss issues affecting patients in Exeter and Cranbrook.

Exeter PPG has had contact with some GPs who say they use other services now, instead of RR, and liaise with the RD&E.

The Ambulance Service frequently are called to admit a patient who has fallen at home. If care packages fail – it falls back to the RD&E.

Feedback
Exeter PPG had asked for feedback from family members and others (around 25/30 people in the Exeter area).

About 80% said patients were being discharged too early and then having to be re-admitted or placed in residential accommodation as there was no care package in place, or parts of the care package were missing. Family members or neighbours would often have to step in to dress etc. However, they said once a care package was in place, it was very good.

On occasions, patients are discharged as fit, but it is their home that is unfit for them to be discharged to, e.g. stairs that can’t be climbed properly where the bed or toilet is upstairs. It seems that assessments are being carried out at the hospital, instead of at home, where stairs and steps can vary hugely.

Some patients are discharged to residential homes and then to home, but this was on few occasions.

There is a lack of recognition of couples and their reliance on each other. Those couples keep themselves well, but if one falls ill, there is often difficulty, as there is little support for the other person who is not in the care system. The whole couple unit should be looked at and not just the individual.

“Only two doctors were left to cover out-of-hours GP services in an area with a population of more than 1.4 million, it has been reported. GPs’ leaders condemned the situation as “completely unacceptable” after a manager had called the staffing level in Kent unsafe in an email to bosses.

The Health Service Journal (HSJ) cited a leaked email that said the two GPs in question were forced to decide who had priority for visits, including some patients in palliative care, besides their own duties during an overnight shift on a weekend in early September.

It said the email was sent at 8am, when the service across most of Kent had 130 people waiting for advice, 67 waiting to be seen at bases and nine visits scheduled. This included at least two palliative care patients in west Kent, one of whom was described as “actively dying” but waited six and a half hours for a visit.

“Patients can’t determine when they will fall ill and they should be able to access high quality GP care when they need to, either through our routine service or GP out of hours services,” said Prof Helen Stokes-Lampard, the chair of the Royal College of GPs.

“It is essential that any out-of-hours care services are staffed appropriately … If patients are unable to access GP care out of hours due to staffing shortages, and GPs working out of hours are being put in a position where they are having to make decisions about which seriously ill patient needs their help most, it is completely unacceptable.” She called for more investment in out of hours services.

According to the HSJ, the email to senior managers read: “I need to let you know that the service is currently unsafe and has been overnight. We had two GPs and one [advanced nurse practitioner] in East Kent and two ANPs in west Kent overnight.”

Out-of-hours cover is provided by the social enterprise IC24. Dr Andrew Catto, its deputy chief executive, said: “In common with many public services, staffing levels in out of hours primary care vary throughout the time our service operates, as certain times are busier than others – especially the weekends, when in-hours primary care is less available.

“It is well known that there is a shortage of GPs. This impacts on many GP surgeries and out-of-hours services. IC24 values the contribution of our GPs. But, in common with other out of hours providers, we benefit from having access to a team of healthcare professionals including nurses, urgent care practitioners and paramedics.

“These highly skilled healthcare professionals meet the clinical needs of our patients using out of hours care. The role of the GP is also changing; rather than needing large numbers of GPs to deliver hands-on care, GPs play an essential role in also providing high-quality expert advice to nurses and paramedics.”

A spokesman for NHS West Kent Clinical Commissioning Group (CCG) and four of the five east Kent CCGs said: “The CCGs monitor the performance of the out-of-hours provider daily, along with weekly reports. There have been no serious incidents reported. Where a gap in workforce is identified, for instance through sickness, the provider puts contingency plans into place. This means that patients will continue to have access to health professionals when they need it.”